Amputation as a Last Resort A Multidisciplinary Approach to Limb Salvage
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1 Amputation as a Last Resort A Multidisciplinary Approach to Limb Salvage George L. Adams, MD, MHS, MBA, FACC, FSCAI Clinical Associate Professor of Medicine University of North Carolina Health System Director of Cardiovascular and Peripheral Vascular Research, Rex Healthcare Raleigh, North Carolina
2 Advance Age 40.3 Million Americans (13%) are age 65 and above. This number will be more than double by 2050 Type I & Type II Diabetes 10.9 Million Americans over the age of 65 (26.9%) have diabetes Diabetes is Am erica s fastest growing health problem Kidney Disease 26 Million Americans have Kidney Disease Diabetes is the leading cause of Kidney Disease U.S. Census Bureau, National Diabetes Fact Sheet Found on American Diabetes Association Website Searched on 27 Sept, 2012 Diabetes Fact Sheet from American Diabetes Association American Kidney Fund Website: News Release 27 Sept, % of Americans w/pad
3 Global Projections For The Diabetes Epidemic: (millions) % % % % % % World 2003 = 189 million 2025 = 324 million Increase 72% %
4 Background Approximately 8-12 million Americans over the age of 40 have PAD. PAD causes morbidity in the form of claudication (a painful cramp in the muscles of the leg with exercise) At its worst, PAD results in failing to heal wounds and ultimately amputation. Am J of Prev Med. 2007;32: J Vasc Interv Radiol. 2002;13:7-11.
5 Fisher, Critical Limb Ischemia. Futura Publishing Company. Armonk, NY: 1999; Jaff, M. EVT. 2004;3:2
6 Patient Survival (%) Peripheral Arterial Disease: All-Cause Mortality* Normal Subjects Asymptomatic PAD Symptomatic PAD ~40% 10-yr mortality Severe Symptomatic PAD Time (yr) *Majority of deaths due to cardiovascular causes Criqui MH et al. N Engl J Med. 1992;326:381 ~75% 10-yr mortality
7 For Healing to Happen, the Pipes Must be Open!
8 Geographic Variation in Lower-Extremity Amputation Raleigh Compared with National Average JACC Vol.60, No 21, 2012
9 Critical Limb Ischemia Evaluation and Diagnosis Dr. Eldon C. Peters, DPM
10 Early Signs & Symptoms Claudication Pain in Thighs/Legs after walking. Cool/Cold Feet Thin Shiny Skin Hair Loss of Toes and Feet Erectile Dysfunction in Men
11 Early Signs & Symptoms
12 Critical Limb Ischemia Ischemic rest pain of legs Non-healing wounds Gangrene Symptoms > 2 weeks
13 Critical Limb Ischemia
14 Diagnosis ABI/PVR Arteriogram Arterial Duplex ABI less than 0.90 = PVD HIGH RISK ABI < 0.79 CRITICAL ABI <0.5 Toe Pressure < 30mmHg Concern for distal leg stents?
15 Prevention & Early Detection
16 Peripheral Artery Disease Revascularization Strategies Martyn Knowles, MD, FACS, RPVI Adjunct Assistant Professor of Surgery University of North Carolina Rex Hospital, Raleigh, NC, USA
17 Adjuncts to diagnosis and to quantify the severity of disease ABIs Underutilized in the identification of PAD Toe pressures Essential due to diabetes epidemic Arterial duplex CTA Aortoiliac disease Pulse Exam Prior history of interventions Hirsch AT, et al. JAMA. 2001; 286: Mozaffarian D, et al. Circulation. 2015; 131: e McLafferty RB et al. Arch Surg. 132:
18 Endovascular Intervention Diagnostic as well as therapeutic Less invasive Shorter recovery and LOS Wide variety of techniques
19 Surgical Intervention Excellent patency More complex disease Excellent in aortoiliac segment
20 Optimal care through multidisciplinary approach Intervention Wound care Research trials
21 Who gets a major amputation? Non-ambulatory Debilitated Beyond revascularization
22 Contact information Martyn Knowles MD University of North Carolina Rex Hospital 4414 Lake Boone Trail, Ste. 108 Raleigh, NC Office: Cell:
23 Panel: The Multidisciplinary Approach Collaboration of Podiatry and Interventional Cardiology/Vascular Surgery Wound Care Management: the latest approach Limb Salvation: how much is enough? Innovations: what novel device and biologic options are proving successful?
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